I have long wanted to post something on what I think is wrong with our health care system. As someone who grew up in a medical family, almost became a doctor himself, and later was a business owner (offering health insurance) and certainly as a consumer, I have a simple explanation as to why our "system" does not work. Some advocates like to toss around the idea that we should let free market forces allow the system to work, but I say the market forces are not AT work, nor ever really were. The true consumer/user (us) is removed from the equation - we consume the services we need. We just pay a co-pay. The hospital bills what it thinks it needs (or wants) to bill, and the insurance company doesn't ever get to argue with the consumer (in general) - we just bitch about co-pays.

We rarely see the bill until the insurance company presents us with it later, and we generally go away thinking "thank god I didn't have to pay that out of pocket" but rarely do we evaluate it as "was that service worth it"?

Well, let me take an example. Dissect it if you want, I'll defend what I can, but I still think it represents a good example of what's not working here.

First, the situation:

I have cancer. That's not immediately specific to this case, but a side-effect of it is. I had abdominal surgery, and the side effect is that sometimes the nervous system of the bladder gets disrupted during this kind of abdominal surgery.

Case is: On a particular day I was feeling a lot of abdominal pain. This was May 29th. My surgery was May 11th, and I think I was there until about the 20th or so. During my time there, I was catheterized. At any rate, I was out about a week.

The abdominal pain I blamed on a blockage (my surgery required me to have a colostomy, joy of joys). It was eventually unbearable. My wife was at work and I finally drove myself to the emergency room leaving my wife a message (but not saying which emergency room, although I hoped she could noodle it out).

Anyway, intestinal blockage was not the problem. Bladder retention was. They catheterized me and took out over 2 litres of fluid. 2 litres! This may not mean much to you (it's over a half gallon, though) but if you're a medical professional, your eyes are probably still in the back of your head by now.

Anyway, they put me up for the night.

I believe I got a CAT scan out of the deal, and maybe an x-ray. I was released the next day.

Well, the follow-up letter from the insurance company come today, just keeping me apprised, what serves as the fragile consumer-price link, except no one cares, unless they want to actually make an issue of the insurance/consumer disconnect, like I happen to want to do.

So, anyway, let's look at it.

Think of what really happened:

- Arrived at the emergency room complaining of abdominal pain- Might have had a CT scan, mebbe an x-ray.- We did a Foley Catheter- Kept me overnight. I don't recall if any meds were given. Certainly they would have been run-of-the-mill- Discharged the next morning before noon.

Mow my mom was an administrator of a non-profit hospital, and I know they had to bump certain charges for "covered individuals" (like for that paper slipper) to make up for those without coverage - spreading the cost of having to "cover all patients", but nothing like this, and I take this hospital to pride itself on a decent reputation.

Somthing, though, is royallaly fucked up somewhere. $11,000 for an exam, so monitoring, and a foley catheter?.

This is what I mean by the disconnect. I agree the "emergency" aspect should add something. I agree other aspcpects should add "something".

Okay, up to a point, but... really...

I know LNA's get $11-$13/hr.

LPNs might get $18-$30/hr

The occasional RN who might have stuck her he head in, $35 to $35 am jpir/

WHERE the FUCK do they get $11,000 FROM? For an overnight visit requiring NO SURGERY, just a catheterizaiton? Something is fucked!

I got seen by a triage nurse, then a doctor trying to figures stuff out...Then they decide to catheterize me and take the pressure of, plus do a CT scanKeep me overnight - nothing special involved in terms of monitoring, as far as I can tell.My wife picks me up around lunch time the next day.

Somethere's wrong here where the only people with price/cost submittal approavel are the holispal and the insurance company.

That's what I think I wrong with out sytem.

I needs to change. Use me an an example if you need to, though other abouses exists.

But isn't this silly? How do you, as a Hosptial Manager, honestly make up this bill. How do you, as a company, honestly submit this bill as a consumer. How would you, as a consumer, honestly want to pay it?

This is where we've gone wrong. Too many markups, not enough controls.

1. Unreimbursed charges. Profit. You must have bad insurance if they didn't knock those prices down

Edited on Fri Jul-10-09 01:48 AM by lindisfarne

significantly (mainly for their own benefit, but you might benefit too, for example, if you have co-insurance or an unfulfilled deductible). Only the uninsured gets stuck with the rates the hospitals/physicians initially bill .

Free market cannot work in health care. Patient has almost no bargaining power. You go in for an appointment - physicians won't (and usually) can't tell you what tests, procedures will be done beforehand. Do you go in, find out what they want to do, walk out, and start calling around other physicians? If you do decide to go with a cheaper physician, you're stuck with a new exam fee.

I tried. I tried oh so hard to get charges on what was a fairly straight-forward "suspicious for glaucoma 2-year follow-up". I had to go to a different office (moved), explained why I was coming in, and tried to get INSURANCE CODES for likely procedures & diagnoses so I could make sure I would be covered. Office refused to give me anything.

Now, a visit for (suspicious-for-glaucoma) is pretty darn straightforward. 90% of patients get a core number of tests (visual field, another I forgot the name on). Since I was at a major medical center attached to a hospital, there was a separate charge & insurance code for physician reading tests.

I could not get office to give me any codes. So, I used the codes from my visit 2 years earlier to check with insurance company (took 2 hours of sitting on hold before they got me answers to all codes - they screwed up one & added an hour to the process while they asked about the 2nd again. That's a whole other story - 2 hours to check benefits????)

Turned out, the codes were identical between the 2 visits (and the good news is the suspicious symptoms are probably normal for me). Now tell me an opthamologist doesn't have a pretty darn good idea of what tests they'd run on someone like me.

I was persistent because a) I wanted to be sure it was covered (total ended up $1200) and b) I wanted to see how possible it was to get such information. It is damn near impossible. (I had just gotten insurance again after being without insurance for over a year; I should have gotten the exam sooner, but knew without insurance, I could not).

This was a fairly straight-forward exam. Now ask - how is someone who goes in with some very unclear symptoms supposed to shop around?

And how is someone with a heart attack supposed to shop around?

The last thing we want is to discourage people with a problem to not get it treated while it's minor. That's why high insurance deductible plans are completely senseless (some do have 1 visit a year they'll cover but I still think they're stupid, esp. when you have kids).

I think the poster has a good point about what the bill is as opposed to what the actual services rendered are really worth. And a little profit isn't a bad thing, but I agree that there is no way they can honestly charge $11,000.

if their wonderful insurance company decides that the patient had a "preexisting condition". So you get to pay not only those ridiculously high premiums, but then get stuck footing an overinflated bill.

June 2006. We both knew she had a stroke. Had no insurance. She refused to let me call for help until the next morning. She had applied for and been told she did not qualify for Social Security as she had worked but a lot of non-covered jobs and had been family caregiver all her life. She had been living on her savings and hoped to live a while longer but she thought if she died so be it.

Ambulance ride as she could not walk or sit up. We told then she had had a stroke and had taken 2 aspirin (and it was correct as she had an ischemic stroke one side of of the brain stem). The charges for diagnosis and treatment until she was admitted were $11,600. The doctor came in and said, yes you had a stroke and we are going to give you two baby aspirin and admit you.

The total bill $136,000wiped out her savings. She was depressed that she had survived her whole right side severely paralyzed, unable to speak clearly and in a whole lot of pain. Medicaid picked up the nursing home, and rehab until I could find a place we could afford to live in Sept.

We got her turned around. She had done so much for others it was time to let others do for her and she has found her niche here in our Seniors building as her sight and hearing are a whole lot better than most and her power chair lets her zip around errands for those with walkers and canes. Besides she is a very nice, smart and funny lady.

Seriously. I had trouble hearing. I had health insurance. So I went to the doctor to figure out why. Compacted wax. Flushed my ears and let me go.

500 Dollars.

This was in 2001.

Screw that. I joined the Navy in 05, didn't pay a dime for anything (including a two week long hospitalisation). Was given free pain killers, cold medicine, whatever. Now I've got the VA, I pay for nothing.

I didn't even know how to use my health insurance while I was on a private plan (which vanished with my job in '02).

So a plan that is incredibly complicated and confusing that costs me a massive ammount of money, or a plan where they give you care when you need it, isn't confusing, and is cheap for me...

12. the hospital you went to, is probably one of many in a conglomeration

Edited on Fri Jul-10-09 06:11 AM by SoCalDem

of hospitals, clinics, etc, and they have CEOs to "bonus", and when all these mergers happen they "eat" debt of the hospitals they buy up (usually a reason they sell in the first place)..

Surely we cannot expect the people who BUY them up, to pay the debts accrued along the way.. They amortize all that debt among all the "clients" that come after..

and if they can no longer get the big bonuses, or the clients drop off, or too many "freebies" get doled out, they load their assets full of more debt, and unload the whole thing to the next sucker, taking big bonuses as they open their golden parachute, into the next "deal"..

I did call the hospital, although I mainly talked to the finanical planning/quote service in Virginia (probaby the hospital is one of many clients).

I believe the hospital is for-profit and a member/client of EMC. I did not chace this fact down.

The bill has a bill to me $100, an ultimate bill $11,000, and a bill to insurance, then a bunch of little "adjustments". I got the impression from talking to the financial company that the hospital has an agreement with the insurance company of what they will or will not pay, so the present the bill, the insurance says "this, this, and this are not covered" but "we will give you a check for such lesser amount", leaving money unpaid which is then "adjusted" off (I assume the hospital eats it, and the financial company basically agreed, without knowning the hospital in-depth, that that is what likely would be happening.

So, since hospitals deal with all kinds of insurance companies, ranging from Sentae-style insurance or Tyco-International companies, to more generic offerings, to the Really Bad Stuff, I'm going to presume (pulling out my Hat-o-Presumption here) that they make up some big-assed bill of what everything theoretically costs and what things would covered if they were dealing with the mother of all insurance companies, presents it, sees what floats, adjusts off the rest, and gives the tiny remainder to the consumer.

REMEMBER - THE CONSUMER NEVER CONFRONTS THE BILLER, AND PAYS ONLY A PITTANCE. THIS IS WHY WE HAVE NO MARKET FORCES IN WORK.

Note that this is a summary listing - it doesn't include the details; ultimaely, though, it's for stomach pain that got a cateter, and some overnight "observation" and probably some Percocets or something. That's all. Oh, plus a CT scan to rule out anything else.

Looking at it and the dates, on the discharge date, they made up the bill. Figured out immediately that about $1,700 wouldn't be covered, so they dropped it and submitted the rest (just under $10k) on June 3rd. A month later (7/3) Harvard Pilgrim springs for about 80% of it, but must have disputed the other $2,800. The hospital drops that, is happy with the $8,200 they snagged from Harvard Pilgrim, and the obligatory $100 from me.

That's their billing system. Nowhere in here do I say this is bullshit. On the other hand, how should I know if a CT was really or truly necessary, or that the hospital johnnie was worth $80? As we said, there's a disconnect, and that's how a trip quick for a blocked bladder ends up with a hospital stay and a catheter and $11,000. What cost the most? Could I have stayed at Motel 6 and had staff visit? Should I have brought my own towels, or perhaps the bag and tubing from the medical supply store? I don't konw!!! I'm the consumer, I CHARGED this stuff, and I don't even know what's being billed on my behalf!!!

16. My explanation of benefits shows each charge and the contractual adjustment individually.

The hospital doesn't "eat" the contractual adjustment in most cases; their "noncontractual" rate is an excessive overcharge (to nail the uninsured who have no bargaining power).

It's no different from any vendor charging their "better" customers less (in fact, Medicare tends to benefit the most from bargaining). The problem is the people least able to pay get nailed - states should mandate that people without insurance should get Medicare rates, or the lowest rate the provider gives to any insurance company.

It looks like your ins. co. paid $8279 for your entire visit and you paid $100.

I don't know of any Motel 6 with a CAT scanner, so no, you couldn't have stayed at Motel 6.

I'm a long-time lurker and this is my first post ever. I have
to share my story so you have something to measure against,
especially as Canadian medical care is quite often vilified
in your press.
My son, who is 17, fell ill at school, complaining of chest
pain. We immediately took him to our local GP who took a set
of X-rays in his offices. It turned out he had a pneumothorax
(collapsed lung). Our doctor immediately sent us to our local
hospital and phoned to let them know we were coming. We were
triaged straight through and were seen by a doctor within 15
minutes of our arrival. More x-rays and they decided to
insert a chest tube and Heimlich valve. After a couple of
hours, and with the lung partially reinflated we were sent
home with instructions to return the next day for
reassessment and tube removal. Unfortunately, upon our return
the next day, the lung had collapsed again and he was admitted
to hospital and put on a suction system, monitored every hour
with x-rays every 4 hours. After a couple of days, the lung
didn't reinflate and we were told he would have to have
surgery. At this point, we were placed under the care of the
head of thoracic surgery. He had a thoracoscopy and
blebectomy (removing a section of the lung) and remained in
hospital another couple of days, still having x-rays and a
few CT scans as well. We have, so far, had 3 follow-up
visits for more x-rays and consults with the doctor. My son
is progressing well.
Why am I sharing this? I just got my hospital bill in the
mail yesterday. Total cost? $56. That was for the phone and
cable TV for 7 days. All drugs were covered.
I know we pay higher taxes than you guys in the States, but I
really think we get our money's worth. I don't care that I
don't use the hospitals often, this was my first time in 15
years here in Canada, but we are all covered and no one is
going bankrupt feeding an already bloated, insurance
industry. My husband has been out of work for the past 11
months and massive medical bills would have put us under. As
it is, I don't have to worry about losing my house, just
finding hubby a job.
Cheers.

And I apologize for the bad typing in my previous posts - I just found my "real" glasses now - the others were "make-do's" that I keep for emergency until I find my real ones.

Yes, my brother lives in Germany. Again, it is "socialized" medicine - they pay huge taxes - but the stuff that really counts is either free or nearly so.

I'm not convinced that if you took a sample of 100,000 people, added up what they spent in taxes, what was spent on them for insurance coverage (through work) that might have otherwise been income (albeit taxed) and what they spent on health care, that they wouldn't be coming out ahead in the higher-taxed-but-basic needs taken care of model.

This isn't "socialism", it's actually a "Keynesian state" (or something - I'm not an economist), but we already pay for other social needs (roads, fire services, police services, etc). It's just that we have their weird opinion that medical care is optional - take better care and you won't get sick. Well, cancer happens, plane crashes happen, houses catch on fire, steam pipes burst at work, whatever. Life changes in mere moments, sometimes.

In some ways, it might make more sense to have socialized medicine and pay-as-you-go fire services. I'm much more likely to be seeing a doctor than a fire truck in the next five years (hoping I didn't just jinx myself with that).

But thanks for listening, lurking, and now contributing! See, it didn't hurt at all!

41. you would never ever hear me critizing Canadian health care, boy howdy!

And your story is a perfect example of why. My gosh, wouldn't it be amazing for the citizens of one of the wealthiest countries in the world to rest assured that the kind of emergency or illness that could happen to anybody any time isn't going to bankrupt them? We must look prehistoric to countries with universal health care.

26. It's unlikely that your HMO disputed that adlustment - rather it reflects the master agreement

Edited on Fri Jul-10-09 03:36 PM by Gormy Cuss

between the HMO and the hospital. Part of the reason that the initial price is so high is that hospitals structure the fee schedule with high price tags in order to net out enough money after such adjustments. Typically hospital fees at list price are double the cost. That's not so that they make a huge profit -- it's so they won't lose money at the negotiated rates.

While it varies by hospital, charges nationally are about double hospitals' costs of providing services, according to Glenn Melnick, professor of health care financing at the University of Southern California. That's up from 10 years ago when charges were about one-third higher than costs, according to data analyzed by Melnick.

But hospitals typically receive less than their listed charges because insurers and government programs such as Medicare and Medicaid negotiate discounts.

"The typical range of discounts nationwide (among private insurers) might be around 45% to 50% on hospital services," says actuary John Bowerline with Milliman USA, a firm that tracks health care costs and consults with employers and health care providers.

Medicare negotiates nothing. Medicare mandates the amount that they will cover and they rarely actually pay all of that. And hospitals are prohibited by law from billing anyone anywhere for an amount above what Medicare allows for a patient who has Medicare coverage.

likely had a fund for indigent, non-insured patients, but unfortunately, many hospitals are capping patient care for this group (decreasing funds allotted for those unable to pay).I've even heard of instances where uninsured patients arrived at one hospital, then were sent to another hospital due to lack of ability to pay for care! I honestly couldn't believe this until I started pharm school and discussed with professors who had seen this type of s**t first hand. Also, last year my sister was having a severe gallbladder attack and she showed up to a hospital around 2am and would not be seen unless she paid her $120 copay upfront. I know this is fact...she called me that night crying. No, she didn't have the money (her husband had a motorcycle accident a few months prior and they were struggling), and she asked if she could be billed. She was DENIED care. She called her doctor, who suggested that she file a complaint with the board and directed her to go to a hospital a few miles further. **If the hospital couldn't afford to absorb some of the cost of your care, you would have gotten the $1000+ bill.

There is the patient, the insurance company and the doctor/hospital/etc.

The patient sees the doctor. The patient has insurance so the doctor agrees to help out and bill the insurance company for the patient (most places do this but a surprising number are refusing to now - more on that later).

The doctor performs the service and submits the bill. The insurance company is not heard from. Maybe they pay the bill, but maybe they don't respond for 6 months. Maybe they "reject the claim" (our clinic just got one that said that the same patient with the same problem and the same diagnostic codes would not be paid for because the same patient with the same diagnosis and the same treatment had the same diagnostic codes as the last bill. Everything is identical and they rejected the claim because it is, er, identical - this type of shit is normal) forcing the doctor to start from scratch, look up old records, spend time researching the problem and resubmitting the bill. The insurance company may again wait 6 months before responding and may again reject the claim. I have seen claims rejected because an "i" wasn't dotted on the form - "meaning is unclear" - WTF?

The doctor, after almost going out of business and having to let go much of her excellent staff, thus compromising patient care, in order to afford about 3 billing experts (the nation average in the US is for 3 billing experts per doctor - isn't that dysfunctional?). The doctor figures out that on average, if insurance companies pay they only pay 50 cents on every dollar. The doctor figures that if she is going to keep the doors open then she needs to bill the insurance companies appropriately.

Logically, a growing number of clinics no longer bill insurance for patient. Instead they practice medicine. The trend is growing. If we let private insurance companies stay involved then more docs will opt out. The reason that many docs do not accept medicare is not that it costs them so much, but that they get inundated with requests once it becomes known they accept it. They literally don't have enough hours in the day and so they close their books to new patients until an opening happens. Single payer would alleviate this problem by opening up the market so you could choose any doctor.

Where do you fit into this? Almost no where. The main thing we hear about insurance companies and patients is the insurance companies denying claims and messing up their lives. This is almost the same thing that they do to your doctor/hospital etc. The benefits of single payer for you would be: no bankruptcy or foreclosure for medical bills, the ability to see ANY doctor in the country (no more stinking "networks" or out of network costs), and no clerks telling your doctor what to do. In Canada it is illegal for someone without a license to make medical decisions, something that happens every hour of every day with private insurance companies.

Yes ER's overcharge, but there is a reason (but not all of that is valid - interestingly single payer countries do not have outrageous charges like these. Why?

Do you see the common thread here?

Insurance companies administrative overhead (not the total overhead) ranges from a low of 20% to a high of 50% with a national average of 27%. No other industry on the planet has such high cost overruns. Your grocery store gets by on a margin of 2 to 4%, which interestingly is the same administrative percentage that Medicare has. And yet insurance companies are posting record profits in a time of recession and inflation - up to 1000% profit. ONE THOUSAND PERCENT!

They deny patients treatment, make medical decisions, and deny payment to your doctor. It's been a sweet swindle and a sweet racket, but it is time to bring an end to this criminal enterprise.

44. Thank you for the post, wolfgangmo. Very informative. I'm not trying to quibble, but

I would like to point out a couple of "anomalies" in your next to last paragraph. Overhead is not "cost overruns" per se, but the cost of doing everything associated with running the business. In the case of insurance companies they don't consider them "cost overruns" because it's what they have to pay to get the result (profit) they want. Margin and overhead are two different animals. Margin is the difference between the actual cost of the service/product (including all those overhead costs) and what the business charges in order to pay for the product/service and overhead costs PLUS make a profit.

The overhead costs for Medicare are in the 4% range, but that is not margin.

The obscene aspect of this, as you point out, is that these insurance thieves are making HUGE profits at the expense of the health of our nation.

"They deny patients treatment, make medical decisions, and deny payment to your doctor. It's been a sweet swindle and a sweet racket, but it is time to bring an end to this criminal enterprise." I couldn't agree more.

I run a small private medical clinic and have no "formal" training in business so I kind of make up my own terms sometimes, ala, "where is the thingamabob that goes on the whosits before we overdrive the gadgetatron and come up with cost overrun, er, thingy?"

On the other hand now that you mention it I do remember my mother mentioning something like that once at the dinner table. Mom ran a publishing company and was a crackerjack business woman. I am standing on a giants shoulders. I must say that it seems that margin and overhead are part of the same wee beastie, more like comparing a hand to the entire arm.

ago. i had broken out in an itchy red rash over most of my body, which benadryl made worse. the nurse examined me and took the info. the doc came in and saw me for less than 5 minutes. he prescribed an IV of benadryl and prednisone which made me worse. they had to stop the IV. they sent me home with prescriptions for yes you guessed it benadryl and prednisone.

the hospital billed my insurance company $1024. they allowed $298 which i had to pay because i hadn't satisfied my deductible. then i get a bill from the doctor. he charged $594. the insurance allowed it, but because my deductible was not satisfied they only paid $96. the doctor billed me for $498, which i haven't paid yet. this for less than 5 minutes.

another case. my mom was taken to the ER by ambulance. she was 85 and her blood pressure was extremely low. she was admitted around 8pm. she passed away at 5:30 am the next morning. all they did was give her fluids. i don't know how much they billed medicare, but medicare paid over $6500. there were charges for the treating doctor too, but i never received any bills. i guess they accepted what medicare paid.

Last summer I woke up one morning with a swollen and sore elbow. I called my Primary Care doctor, who was unable to see me that day, but advised I go to the local ER.

I went down to the UMass Medical Center. The ER there has a very nice process called 'fast track'. If you walk in with a very specific set of symptoms; ie; big swollen elbow, an ER nurse diagnoses you in about 30 seconds and sends you into a waiting room. In about 5 minutes an MD comes and treats you.

This is exactly what happened to me: the doctor came in and said 'nice olecranon bursitis ya got there', took a sample of the elbow fluid and prescribed Keflex. I was in there for no more than 6-8 minutes. A few weeks later all was well.

The bill for the visit was $2200 from the hospital and ER, and another $500 from the ER doctor. The insurance company paid the $2200, and advised me not to pay the $500, as they would negotiate it away.

I never head from anyone again, but I was mortified that a 10 minute stay was $2700.

jeez...my son had a concussion last monday. they gave him a cat scan, admitted him, gave him fluids, and released him the next day. thank god i have insurance. his stay must have cost at least $25,000.

58. All of these stories of huge ER bills are why we NEED single payer.

Shit like this just doesn't happen in countries with single payer. You go to an ER, you get treated, and you leave. Last time I was in one in Canada I had a broken arm. They x-rayed, set and cast it, gave me pain meds and a prescription and THEN asked for my government insurance card. I told them I was from the US and they told me to wait a second. The billing person came to me and handed me the bill and told me to send them a check. The bill was for $57 dollars.

The reason we see such outrageous bills and off the wall stories in the US is because the hospitals and insurance companies are in a race to see who can screw the other over more. It is a system that is set up to be antagonistic and has nothing to do with good care. FYI the New England Journal of Medicine did a study that found that wait times for ER in the US are longer than any other industrial nation. How sad is that?

27. Once upon a time I went to the hospital for a bad case of septicaemia.

I was there for about five days, I think, although I don't remember the first couple of days all that well.

No surgery. No high-end therapies. Just an IV, meds, meals, supervision, and a blood drawn a couple of times for testing.

It was a miserable experience because all I wanted was quiet and the roommate kept her TV on all the time, had visitors streeling in and out, and the nurses never let me sleep for more than a couple of hours without coming in to mess around with the IV or make me take a pill or do something in the bathroom or whatever. Conversely, though, whenever I could have really USED help, they were nowhere to be found, surprise surprise. And the food was inedible.

I, too, had insurance that paid most of the freight although I ended up on the hook for nearly two grand in co-pays.

I worked out what it would have cost me for the following:

Top-quality room (though not a suite) at the best hotel in town for five days.Room service meals for five days.Three shifts (24 hours) of private duty skilled nursing for five days.All meds from a regular pharmacy. Plus IV supplies, hanger, etc.Rental of a wheelchair.Medical transportation (not an ambulance, but the next level below) 1X a day for five days, to get bloods drawn, to see a doctor, whatever.

The hospital stay cost more than that. A lot more.

It didn't make sense to me then, and that was twenty years ago. It still doesn't make sense.

What you are talking about is a natural result of insurance medicine, which is a type of medical practice that is ONLY practiced in the US.

Insurance medicine is particular in that doctors will not make a move without first checking to see if the insurance companies will pay for it. And because the insurance companies only pay per procedure, they are structured just like a shyster car mechanics place. The faster they can do a procedure, the more they make. This is why there are so many specialists in the US.

I've been in hospitals in the US, Canada, England, France, Costa Rica and Venezuela. The US was the worst by far. Longest wait times, fewest staff, most questions about ability to pay and no treatment until you establish that.

You could be holding your liver in your hands with blood pouring out of your eyeballs in the US and you better have that insurance card ready or no help for you. "Press hard please, you are making 3 copies. Sign here. And here. And here. And here. ... And here. Can I see your proof of citizenship, drivers license, insurance card and a major credit card. Please sit over there. "

31. Another reason why hospital bills are so high is those who are underinsured...

....by Medicare. I wonder how many people are aware of how much of a beating hospitals take on Medicare patients. Example:

My father's last hospitalization. Nineteen days inpatient, four of them in Critical Care, three in a dedicated oncology unit where an elevated level of care is provided 24/7, one major surgery, several more minor procedures, absolutely outstanding nursing.......we had no complaints about what was done for him and the hospital's regular charges for the level of care he received over that period of time, $43,931.36, didn't seem to be way over the top by today's standards.

Of that $43,931.36, Medicare allowed a whopping $12,038.72, leaving the hospital holding the bag for $31,892.64 that by Federal law they couldn't bill anyone for; not my Dad nor his supplemental insurance.......no one. Say what you like, there's no way in Hell that hospital even broke even on less than $650/day even if the care hadn't been as good as it was. Forget about even enough in the way of profit to cover equipment upgrades, etc.

Physician's don't take quite as big a hit from Medicare, but they rarely get approval for more than 50% of their charges for major services and if they accept Medicare payments, again, they cannot, by law, bill anyone for anything above the Medicare-approved amount. Doctors can't, so far as I know, refuse to treat patients who are on Medicare, but they can opt not to accept direct Medicare payments, alleviating them of the restrictions against billing for any balance above the Medicare-approved amount, so it pretty much amounts to the same thing. Hospitals don't have that option.

Is it any wonder why they bill non-Medicare patients and their insurance companies more than, on the surface, their services may seem to be worth in an attempt to make up at least part of the difference? Is it any wonder why some in the medical community are leery of any kind of a Medicare-for-all solution?

Coding is standardized. Has been for well over 20 years. And, at least for hospitals, HCFA standardized the forms sometimes in the early 80s, too.

With some insurers, however, collecting can be a major chore and add to costs for all. Having contracted in collections for a medical billing service a couple of years ago and I will agree that some, certainly not all, insurers were incredibly difficult to deal with, which can't help to add to costs.

First ... Yes ICD9 codes and AMA procedural codes are standard. WHAT IS NOT standard is the secret list of what will and will not be paid for. I used to work for BCBS and they had different billing criteria in the "just say no" floor (as we called it) every day. The team leaders would show up for the team meetings and talk about the "NO" of the day.

ALthough our clinic does not bill insurance anymore (like many primary care physicians we can no longer afford to fight your insurance company for you in order to get paid), but against my better judgement and as a favor for a friend we decided to. I just go a stack of insurance explanations for review. These are all for the same patient, with the same diagnosis, the same insurance and procedural codes and stem from the same incident (car accident). They are normal standard of care treatments.

Some of the bills were paid and others weren't. Why? Because some of them have the same CPT/HCPCS (insurance) codes on them. WTF? That's right. They are paying some because it is the same code/treatment/injury/patient and not others for the same reason. Is it just me or does it seem that they system is perhaps a not exactly the paragon of free market efficiency?

Second ... Malpractice insurance payout and premiums are very low in other countries and the reason why is that the biggest cost in a malpractice insurance suit is the cost of continuing medical care, WHICH IS ALREADY PAID FOR UNDER UNIVERSAL SINGLE PAYER. A few years ago our medical director asked me to look at the feasibility of moving the clinic to Canada. I did and found that malpractice insurance premiums were WAY lower and the nice insurance dude explained why. Lower pay out. Lower premiums.

What many physicians are leary of is a medicare-for-all solution that is massively underfunded. Which is not what ANYONE except Rush Limpballs and assorted ilk are talking about. Medicare is underfunded, but if you think that Canada, the next highest cost per person per year for health care and they get everyone covered for the grand amount of about $3600 per year per person - ahem - rant over, can afford to do what they do and we spend about $7200 per person per year already in the US, if we went to the same system, funded the same way, then the US medical system would be a mercedes s class instead of the 1976 Pinto we now have to contend with.

Any doc I have explained this to gets it. I have started to tell anyone who mentions "socialized medicine" as if that means something to stop wrapping tin foil around their heads. I figure if you act like a loon, you get treated like one.

First to some very rich people who own, manage, and profit from hospitals.

Second is that those costs help defray whatever costs the hospital incurs from those who cannot pay. That is the part that the republicans and blue dogs don't mention when they say how much single payer would cost. We are already paying for many who do not. Better that it come from everyone in taxes and not include excess profits for fat cats and insurance.

That's how Bill "Cat-Killer" Frist made his big bucks. His family owned one of the big hospital chains.

You are correct on hospitals defraying the costs of those who cannot pay, as well. I worked for a summer in a hospital's billing office one summer while I was in college. That's how they did it, and that was a non-profit hospital. When I hear someone complain about paying for "the lazy people" (as they call them), I point out that they already do, and always have. The complainers also never seem to understand that the insurance companies are not their friends, and look for every chance they can get not to pay out when these people get sick.

I am stuck in a temp job, which has no insurance. I cannot afford anything but the most rudimentary insurance, with ultra-high deductibles. My friends were shocked when I told them that I was better off without it. For minor stuff, I would wind up paying out of my pocket anyway. For serious conditions, the insurance company would find a way to not pay out. Why should I pay them money that I can't really afford and wind up screwed anyway?

broke his foot. He spent a week in pain since he has to stand for his job. He did the research to find the cheapest way to get it treated. It involved using low income medical help and benefits. We all paid for it.

People who complain about not wanting to pay for "those people" are both stupid (because they already are paying for them) and selfish. Hey. That sounds like republicans to me.

35. Sounds cheap compared to the $4000 bill we got for a dislocated shoulder

My son spent a total of 3 hours in the ER, got moved to a different room because the nurse didn't believe his shoulder was dislocated. So we had two room charges on top of four x-rays. No ambulance call. No overnight visit. No funky medications or strange procedures. Just a little pain medicine and a hard yank on the arm.

I couldn't believe the bills when they arrived. And this was five years ago.

42. I've been where you were recently--hospital stay of 3+ days for hip replacement--

that generated a $37,000. bill--not including surgeon's fees. I've also been on the other sideas a hospital administrator required to develop budgets that met patient needs.

There is no doubt that our system is majorly messed up. Many other countries provide excellenthealth care services--with better results than we do--for lower costs.

Just cutting costs--instituting controls as you suggest--is not going to solve the problem.There are many services in the hospital that are not billing centers, but are necessary to runthe facility. Medical records, accounting, purchasing, dietary, information management, housekeeping, laundry, risk management, maintenance, biomedical engineering...I could go on and on. All the expenseof those departments has to be incorporated into the billing centers that provide patient services.

The other side, which you have mentioned, is the fact that many hospitals (often not the for-profit ones)end up treating patients who have no resources. Their care is unreimbursed. The cost of providing that care is loaded onto the "paying" patients in the form of higher bills.

The whole system is totally out of balance--out of whack. For my money, I'd like to see single payer.Everybody gets covered for some level of care. Take the insurance companies (and their profit margins)out of the equation and there would be plenty of funds available to cover the uninsured. There wouldn't be a gazillion different billing forms required; there wouldn't be entire departments devoted to insuranceverification.

Power does not relinquish power without a fight. The insurance companies aren't going to walk away from their profitable business. I don't know the answer. I do know that simply instituting cost controlsat the point of service will not solve the problem.

About 18 months after the original problem, I had symptoms consistent with the first go-round. I went to the ER and they admitted me over night for a couple of tests and observation. Basically a CBC and an ultrasound on one of my legs.

us consumers (patient's) need to organize too. It's the only way we've been able to provide safer patient care without mandatory overtime and unsafe staffing levels.

Consumers don't necessarily have to form a union, but we DO need to organize - FULL PRESS on Congress and the White House to do the right thing. The insurance and pharm big businesses are not going to give up without a huge fight.

It would be great if we could fire all of the insurance companies and pharm companies (without harming anyone needing care/meds - dream on).

I described what I was doing - basically just trying to put together some kind of article on the premise that there are no market forces - the buyer (me) never gets to confront the negotiator or payor as to the price.

The discussion we had is worth another article, but for now let's at least say it dovetails with this one.

The scary thing is, I described the situation (which she remembers) of when I went to the emergency room) and what I got (CT scan, catheterization, overnight stay).

She's been out of the business directly for a while, but her answer kind of scared me. She thought about it for about all of 5 seconds and then ventured "$10,000?".

A few years ago when I was without insurance for a period of years. I noticed 2 small lumps in my testicle. Without a doctor I finally went to the hospital to find out the story. It took some time to get my nerve up since it was a little embarrassing. I got checked in waited for 2 hours, had my weight and blood pressure taken, waited and finally someone saw me and felt the lumps. His words were, "You have a lump there, you should get that checked out." He left a nurse came in with a couple Urologists I should call and I was discharged. I called the Urologists and not a one would see me because I lacked insurance. In the meantime I received a Bill for $575 so some guy could tell me something I already knew, that I had lumps in my testicle that should be looked at.

So I gave up and waited a few years till I had insurance and was able to get it looked at properly. Luckily it was nothing and I am fine, but what if it was testicular cancer and I was denied care because I had no insurance? I may have died or had to undergo much more expensive treatment due to being turned away.

It;s flat out among the worst Health Systems in the entire World and somehow people still defend it.

Why even list an idiotic obscene price like that if nobody really pays that. I honestly want to kick their asses (or worse) when I see such infantile abuse by the hospitals. Do they think they can do anything they want and we will just take it?

57. Another problem is that we get a series of obscure bills identifying the

date of services, but not what each service ws or what it cost. Months after having been to the hospital for outpatient tests, I am still getting mysterious bills with no indication of what hare for. Sometimes the bills look exactly like bills I have already paid, but since they are not itemized, I can't even tell if I am being double-billed.

i caught a $7000 dollar error they billed my state insurance carrier & Workman's comp twice even when they had direct knowledge that my injuries were Workman's comp. I then had physical therapy which should have been billed to comp but was done to my state insurance. They kept billing me above and beyond what was paid & covered. It took five times to the Insurance people to stop them from sending my unpaid portion of the bill to a collection agency. They billed for every hot pad and ice pack..amazing when I was only responsible for the co-pay period which was paid. I am waiting to see how messed up it get now that I have SS disability requiring medicare as the primary. My comp carrier wants me to stop going to the chiropractor since they believe I will never be cured..pretty screwed up since I also use a massage therapist twice a month that they don't pay for. They would rather pay for pain meds.

64. I've read much of this thread. You know what the politicians are afraid of with single-payer?

Where the gov't pays for your medical care with higher taxes? They fear that they will have to contend with many angry voters who are going to resent having their tax dollars paying for some other person's (foreigner's, hispanic's, black's, gay person's, what have you) medical care. They fear the voters who view single-payer as socialism in practice.

She wound up spending a couple days in the hospital, had x-rays, cast, the whole nine yards. I just recently found the bill for this whole mess. It was MOST interesting, as it was written up on a carbon receipt machine. Basically, it stated something like 3 days hospital care, x-rays and cast. This was in 1958, and was not covered by insurance. The total bill?? $54.00.

In Portland Maine recently, a kid fell and scraped his chin, got examined by a doc, didn't' even need stitches, just a band aid.

The bill came a month later, COST: $930!! for an effin BAND-AID!!

THIS IS BEYOND INSANE.

I believe the solution to our health care costs is multifaceted:

We need to move towards single payer to help keep the costs down and in line with reality- for now a public option as Obama has suggested to offer a NON-PROFIT option. A public option would also encourage more preventive care, as the incentive would be for health rather than profit. We would also be able to use the large pool of public option participants to negotiate for lower drug costs.

We need to keep cost down by modeling health care services after those communities, like the Mayo clinic, that pay their doctors on salary, rather than fee for service, and focus on best health outcomes, not highest profit.

We need to educate and have programs and incentives for Americans to take better care of themselves- exercise, eat healthier food etc... preventive care is so much less expensive than emergency room visits, surgury, and other expensive interventions.

We need to stop the govt. subsidy for corn that results food corporations using in high fructose corn syrup as a sweetener(linked with numerous costly health issues including diabetes and obesity)

With this plan, we could come in line with other industrialized nations, covering everyone for half the cost we currently pay. Right now we are ranked 37th in the world- really pathetic.

IT'S A NO BRAINIER, but there are those pesky profits that insurance and drug companies are making and now lobbying congress at an astounding rate of $1,400,000 PER DAY to keep us from having a public option.

Each one is so different and they all find a way to not pay for things. Luckily I haven't had anything bad happen yet. Had gum surgery that cost me over $2K but that wasn't bad.

The thing about the insurance is they make up what they will and will not pay. I cut my finger a few years back and went to the emergency room to get stitched up. Actually I would have done the normal path of super gluing it back together but since it was a rusty blade and it had been 14 years since my last tetnis (sp?) shot, I went to get one and stitches. We when the bill eventually came, they didn't cover most of it. I called to ask why. The Emergency room was in my network so I didn't see why it wouldn't be covered.

The reason: the doctor that night was a contractor.

So what I got out of this is that if I am going to have an emergency, I need to call the hospital ahead of time and schedule it when they will have an actual doctor.

Powered by DCForum+ Version 1.1 Copyright 1997-2002 DCScripts.com
Software has been extensively modified by the DU administrators

Important Notices: By participating on this discussion
board, visitors agree to abide by the rules outlined on our Rules
page. Messages posted on the Democratic Underground Discussion Forums are the
opinions of the individuals who post them, and do not necessarily represent
the opinions of Democratic Underground, LLC.